Your Details

Title: Surname: Given Names:

Email: Date of Birth: Gender: Marital Status:

Medicare No: Ref No: Expiry Date: / Private Health Fund:

Pension, Health Care Card or Veterans Affairs Number (if applicable): Expiry Date: /

Occupation: Employer:

Home Address:

Postal Address (if different from Home Address):

Phone (Home): (Work): (Mobile):

Emergency Contact Details

Name: Relationship to you:

Phone (Home): (Work): (Mobile):

Australia is a genuinely multicultural society. To tailor appropriate care, encourage understanding and appreciation between people from different nationalities and backgrounds –Do you identify as someone from a culturally and/or linguistic diverse background?

Yes - Please indicate ethnicity:

To assist with health initiatives - are you Aboriginal or Torres Strait Islander?

List your allergies & intolerances to medications:

List your regular medications and doses & over the counter medications and doses:

Do you smoke?: If 'Yes' number per day: Year quit (if applicable):

Our practice undertakes research, professional development, and quality assurance/improvement activities to improve patient care. All people accessing personal health information for this purpose have signed a written confidentiality agreement.

I consent to my health record being reviewed as a part of the quality improvement activities in this practice:

Our practice uses a reminder system to improve the quality of your health care. The practice sends reminders by mail or telephone for procedures such as vaccinations, pap smears and other health reviews.

I consent to being contacted with reminders.

Please advise us if your contact information or Medicare details change.

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You can also download the New Patient form to print and fill out. You can send it to us by:

Post: T13, 222 Fischer Street, Torquay, VIC, 3228

Email: info@tqfhc.com.au

Fax: (03) 8679 4444